Healthcare Hygiene magazine October 2019 | Page 29

leads to the implementation of inherently safer systems,
where the risk of illness is substantially reduced.
The traditional occupational health hierarchy was formally
created in the 1960s for use in non-healthcare industries
like manufacturing, mining and construction. It is used as
the basis of federal and state occupational safety and health
regulations, including the Occupational Safety and Health
Administration (OSHA). For example, the OSHA Bloodborne
Pathogens Standard has resulted in unnecessary needles being
eliminated wherever possible, reducing the risk of needlesticks.
If a needle cannot be eliminated, can it be substituted for
something less hazardous? This might mean using blunt fill
needles to draw up medications from multi-dose vials.
If a needle cannot be eliminated or substituted out, can it be
engineered to be safer? Disposable hypodermic needles with
sharps injury prevention features (e.g., sheathing or retracting
needles) are a perfect example of engineering controls.
If a needle cannot be engineered to be safer, are there
work practices or administrative controls that can be put into
place to reduce sharps injuries? This includes safe disposal
practices and careful attention to surgical team safety when
using no-hands or neutral zones for surgical instruments.
If none of these controls can be out into place or there
is still an exposure risk after the higher controls have been
implemented, does personal protective equipment (PPE)
need to be used? Must a single or double pair of gloves be
worn? Is there risk of a blood splatter, necessitating a gown
and/or eye protection be worn to protect someone at the
patient bedside?
PPE is the lowest and least effective control on the hierarchy
for many reasons:
➊ It must be available to the healthcare worker when
and where it is needed. It must be immediately accessible
to them.
➋ The worker must make the decision to put it on.
➌ The worker must be properly educated about risk, so
they are more likely to use it.
➍ The worker must be educated about how to properly
put it on (don) and take it off (doff) and to safely dispose of
PPE so as not to contaminate themselves or inadvertently
expose anyone downstream (e.g., environmental services
and waste haulers).
➎ The PPE must work. It cannot have gaps or tears or
an undesirable level or permeability.
➏ Multiple pieces of PPE must be compatible. If a pro-
cedure can result in a risk of a blood or body fluid splash or
splatter (mucocutaneous), can eye protection be worn in an
addition to a respirator? Or is the isolation or chemo gown
long enough to cover the wrists in addition to glove use?
➐ Cost and disposal are concerns. Since most PPE is
disposable, providing PPE everywhere it is needed can be
costly and if it is not properly disposed of, it can pose a risk
to workers downstream. And since PPE is disposable, are
there additional occupational or environmental concerns
when PPE materials (e.g., latex, nitrile, vinyl) are made?
In infection prevention and control as well as in envi-
ronmental safety and health, professionals have focused
www.healthcarehygienemagazine.com • october 2019
heavily on PPE use as required by contact, isolation and/or
transmission-based precautions. Why do we focus on PPE
for infection prevention and patient safety, often as a first
line defense and not in occupational health and safety?
Why do healthcare institutions focus on work practices like
properly cleaning and disinfecting environmental surfaces and
cleaning and sterilizing surgical instruments and manufactur-
ers are not held accountable and responsible for ensuring their
materials and products meet the demanding requirements
and needs of healthcare facilities and professionals.
There is a great deal that the infection prevention and
environmental services community can learn from their
occupational health and safety partners, including ways to
integrate the hierarchy of controls into their processes, policies,
and practices. Neither infection prevention nor occupational
health have more resources than they need to reduce risks
for the patients and providers they work to protect. The most
effective programs are those that partner “across the aisle”
and share not only resources, but expertise and experience.
(Reference: https://www.cdc.gov/niosh/topics/hier-
archy/default.html)
The Hierarchy of Controls:
• Elimination: Physically remove the hazard;
Institutional Controls: Culture of safety
CLICK HERE FOR
• Substitution: Replace the hazard
Hierarchy
• Engineering Controls: Isolate people from
of Controls
the hazard
• Administrative Controls: Change the way people
work and interactive with their environment
• PPE: Protect the worker and patient with barrier controls
Integrating the application of the Hierarchy of Controls
to the Seven Aspects of Surface Selection look like this.
It is believed that to reduce the risk of healthcare associated
infections (HAIs) and occupationally associated infections
(OAIs) one must clean, disinfect, and sterilize surfaces,
devices, instruments, textiles, and patient care items better.
This certainly is one aspect of the solution. Unfortunately,
it will not adequately address the problem.
When all aspects are included in the Hierarchy of Controls,
a proactive strategy becomes clearer and more distinct.
Patient and healthcare worker risks are minimized, and
sustainable solutions and relationships can be realized.
Linda Lybert is president of Healthcare Surface Consult-
ing and the founder/executive director of the Healthcare
Surfaces Institute.  
Amber Hogan Mitchell, DrPH, MPH, CPH, is president and
executive director of the International Safety Center and a
member of the board of the Healthcare Surfaces Institute.  
Glenda Schuh, RN, BSN, CIC, and Caroline Etland, PhD,
MSN, reviewed this article. Schuh is a consultant in infection
prevention and occupational health. Etland is currently an
associate professor at the University of San Diego Hahn
School of Nursing, and a clinical nurse specialist at Sharp
HealthCare. They both serve as board members of the
Healthcare Surfaces Institute.
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